Abstract
BackgroundBovine surfactants are known to be clinically equivalent but it is unclear if porcine or bovine surfactants at their licensed dose should be preferred to treat respiratory distress syndrome in preterm neonates.MethodsWe performed a comprehensive review of biochemical and pharmacological features of surfactants to understand the biological plausibility of any clinical effect. We then performed a pragmatic meta-analysis comparing internationally marketed porcine and bovine surfactants for mortality and respiratory outcomes. Search for randomised controlled trials with no language/year restrictions and excluding “grey” literature, unpublished or non-peer reviewed reports was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the most recent methodological recommendations.ResultsSixteen articles were included in the review and 14 in the meta-analysis (1491 neonates). 200 mg/kg poractant-α (a porcine surfactant) was associated with lower BPD/mortality (OR 0.632[95%CI:0.494, 0.809];p < 0.001),BPD (OR 0.688[95%CI:0.512, 0.925];p = 0.013), retreatment (OR 0.313[95%CI:0.187, 0.522];p < 0.0001), airleaks (OR 0.505[95%CI:0.308, 0.827];p = 0.006) and lung haemorrhage (OR 0.624[95%CI:0.388, 1];p = 0.051). Gestational age is associated with effect size for BPD (coefficient: 0.308 [95%CI:0.063, 0.554];p = 0.014) and surfactant retreatment (coefficient: -0.311 [95%CI:-0.595, − 0.028];p = 0.031).Conclusion200 mg/kg poractant-α is associated with better respiratory outcomes compared to bovine surfactants at their licensed dose. The effect of poractant-α on BPD and surfactant retreatment is greater at lowest and highest gestational ages, respectively.Trial registrationPROSPERO n.42017075251.
Highlights
Bovine surfactants are known to be clinically equivalent but it is unclear if porcine or bovine surfactants at their licensed dose should be preferred to treat respiratory distress syndrome in preterm neonates
Eligibility criteria We looked for randomized controlled trials fulfilling the following criteria: 1) published as full articles or as abstracts presented at the Paediatric Academic Societies (PAS) or European Society for Paediatric Research (ESPR) meetings; 2) enrolled preterm neonates with clinical and/or radiological established evidence of Respiratory distress syndrome (RDS) needing intubation; 3) compared porcine and bovine-derived surfactants; and 4) reported at least one of the selected outcomes
Surfactant-protein content is variable and poractant-α is the preparation with the highest protein concentrations
Summary
Bovine surfactants are known to be clinically equivalent but it is unclear if porcine or bovine surfactants at their licensed dose should be preferred to treat respiratory distress syndrome in preterm neonates. When optimal prenatal care is provided, the best approach to treat RDS, according to several recent trials, [4] consists in providing continuous positive airway pressure from the first minutes of life using short binasal prongs, [5] followed by early selective surfactant administration for babies with worsening oxygenation and/or increasing work of breathing. Both European and American guidelines advise in favour of this strategy, which reduces mortality and broncho-pulmonary dysplasia (BPD) [6, 7]. Animal-derived surfactants may carry pharmacological and biochemical differences and these latter might influence clinical outcomes
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